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SAN JOAQUIN CStNTY ENVIRONMENTAL HEALTH DEPfsRTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF & y(I Z <br /> OWNER/OPERATOR Yellow Freight CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME Yellow Freight-Tracy <br /> SITEADDRESS 1535 Pescadero Ave Tracy 95304 <br /> Street Number I Direction Street Name City zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE CA ZIP <br /> PHONE 91 ExT' APN# LAND USE APPLICATION# <br /> 1 l <br /> PHONE#2 ExT BOS DISTRICT LOCATION CODE <br /> ( l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS® <br /> BUSINESS NAME Service Station Testing-SST INC/CSLB 962520 PHONE# E <br /> 209 1 465-5577 <br /> HOME or MAILING ADDRESS FAx# <br /> PO Box 31465 (209 ) 4654988 <br /> CITY Stockton STATE CA ZIP 95213 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: c r-N� DATE: 12/11/13 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT® President <br /> I,fAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: etiwVM{� C^ <br /> COMMENTS: Replaced L-3 sensor(Waste Oil sump)at T-1. I'91r�aEIVGL/ <br /> DEC 11 2013 <br /> EJOAQUIN COU <br /> NVIROMENTALNV <br /> pARTMENT <br /> ACCEPTED BY: EMPLOYEE#: O 6 SLCJ DATE: 2 I3 <br /> ASSIGNEDTO: T�(�-,� EMPLOYEE#: 27�iLG/ DATE: /ZA I <br /> Date Service Completed (if already completed): 12/10/13 SERVICE CODE: 9 k P I E: 30� <br /> Fee Amount: �� Amount Paid _ Payment Date <br /> 10ith -3 <br /> Payment Type ,/ Invoice# Check# Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />